This bill reforms the Medicare Advantage program by requiring the federal government to audit and standardize prior authorization rules for high-cost medical services and prescription drugs. Starting January 2027, the Department of Health and Human Services must identify the most expensive covered items and services where prior authorization processes are overly complex but have solid medical evidence supporting them. By May 2028, the agency must create uniform prior authorization standards across all Medicare Advantage plans nationwide, eliminating the current situation where different insurance plans have different approval requirements for the same treatments. The bill includes an exemption: healthcare providers participating in value-based risk-sharing models, such as accountable care organizations, would no longer need prior authorization for these standardized services—though Medicare Advantage plans can request an exception to continue their own approval processes. The legislation primarily affects Medicare beneficiaries enrolled in Medicare Advantage plans and the insurance companies that administer them, streamlining the approval process to reduce delays in patient care without explicit new federal funding specified in the bill text.
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